This week the press is buzzing about a new study just published in The British Medical Journal (linked here) on medical errors in the United States. It certainly is something we High Reliability Mindset proponents already know about, but the study presents a new angle and refreshing take on one of the most critical issues in healthcare. It has also been the topic of this blog for the past 5 years.

The authors from Johns Hopkins Medical School have used a new epidemiological algorithm that tries to identify the root causes of medical related deaths, such as those due to medical errors, inorder to calculate more accurate death rates. Usually, death rate statistics are based on the cause of death that docs fill out on the death certificate and that is the traditional cause of death (i.e. “cardiac arrest”). This is the immediate issue that led to the patient’s demise but not necessarily the deeper root causes of the death. The authors reason, and correctly I believe, that this is not really a cause of death but more realistically a metric of death itself and therefore not truly reflective of deaths due to errors. For 17 years now, statistics on death due to medical error have been discussed in terms of the famous Institute of Medicine report that was optimistically entitled, “To Err is Human”. The 1999 IOM study puts the number of deaths due to medical error at about 98,000 per year in the US. Using these newer methodologies the BMJ study puts that number closer to about 300,000 and that makes this the third leading cause of death in the US.

Of course statistics can be bludgeoned into any conclusion that the statisticians want, but this new review is an honest and thoughtful study that takes a fresh look at this chronic problem and comes up with new and insightful data. As adopters of The High Reliability Mindset, we agree with the conclusions of this report. It states that, “Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences. Strategies to reduce death from medical care should include three steps: making errors more visible when they occur so their effects can be intercepted; having remedies at hand to rescue patients.”

As we have discussed right from the first post on this blog, the basic fact is that human error will occur, so we must engineer a system that traps these small missteps early and prevents an ultimate catastrophe to our patients. We must fight this problem also by understanding when and how error occurs and maintain a constant vigilance to prevent these potentially fatal mistakes. Click on any link on the main page to find HRM tools that will help accomplish this aim.